COMPULSIVE DISORDER

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A COMPARATIVE STUDY OF CLINICAL FEATURES, QUALITY OF LIFE IN OBSESSIVE

COMPULSIVE DISORDER

Dissertation submitted in

THE TAMILNADU

Dr.M.G.R.MEDICAL UNIVERSITY

in partial fulfillment of the regulation for the award of

M.D. (PSYCHIATRY) BRANCH - XVIII

GOVT. STANLEY MEDICAL COLLEGE & HOSPITAL THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY

CHENNAI, INDIA

MARCH 2010

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CERTIFICATE

This is to certify that this dissertation entitled “A COMPARATIVE STUDY OF CLINICAL FEATURES, QUALITY OF LIFE IN OBSESSIVE COMPULSIVE DISORDER” is a bonafide work done by Dr.R.JAISINGH, in partial fulfill

ment of the requirements of GOVT.

STANLY MEDICAL COLLEGE & HOSPITAL, THE TAMIL NADU DR.M.G.R. MEDICAL UNIVERSITY, Chennai for the award of M.D.

Psychiatry Degree.

GUIDE

Prof.Dr.A.PRIYA, M.S., D.O., DEAN

Govt. Stanley Medical College & Hospital, Chennai – 600 001.

Prof. Dr.M.THIRUNAVUKARASU, M.D., (Psych)., DPM, FIPS., Professor & Head of Department, Department of Psychiatry

Stanley Medical College & Hospital Chennai – 600001.

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ACKNOWLEDGEMENT

I wish to thank Prof.Dr.A.PRIYA, M.S., D.O., Dean, Stanley Medical College for permitting me to carry out this study.

With sincere gratitude, I wish to acknowledge the expert guidance and precise suggestions of Prof.Dr.M.THIRUNAVUKARASU, M.D.,

(Psych), DPM., FIPS, Professor and Head, Department of Psychiatry

who has helped in designing the study. I thank him for being a constant source of encouragement, inspiration, not only in this study but in all my professional endeavours.

I sincerely express my grateful thanks to

Dr.G.S.CHANDRALEKA, M.D., DPM., Additional Professor,

Department of Psychiatry, for being a constant source of encouragement and inspiration in this study.

I express my profound gratitude to Dr.M.SURESH KUMAR,

M.D., DPM., MPH., consultant psychiatrist, Chennai.

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My sincere thanks to Dr.S.NAKKERAR, DPM., Assistant Professor, Institute of Mental Health, Chennai and Dr.M.MOHAMED

ILYAS, M.D., DPM., Assistant Professor, Department of Psychiatry for

their constructive criticisms, without which this work would not be in the present shape.

I sincerely thank

Dr.V.VENKATESH MATHAN KUMAR, M.D.,

Assistant Professor, Department of Psychiatry.

I wish to thank all my Co-postgraduates and other staff members of the Department without their help this thesis would not have been completed.

I extend my thanks to all patients who participated in this study.

Above all, my whole hearted thanks to my parents, family members and

friends for their moral support and encouragement.

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INDEX

SL NO. TOPIC PAGE NO.

1. INTRODUCTION 1

2. REVIEW OF LITERATURE 4

3. AIMS AND OBJECTIVES 9

4. MATERIALS AND METHODS 10

5. RESULTS AND DISCUSSION 17

6. LIMITATIONS 53

7. SUMMARY AND CONCLUSION 54

REFERENCES APPENDIX

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Perceived quality of life in obsessive – compulsive disorder: related factors.

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obsessive – compulsive disorder. : overview and quality of life issues. J Clin Psychiatry 1996.

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16 Quilty LC, Van Amerigen M, Mancini C, Oakman J, Farvolden P. Quality of life and the anxiety disorders. J Anxiety Disord 2oo3.

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21. Besiroglu L, AS, Cl, Askin R. The predictors of health care seeking behaviour in obsessive – compulsive disorder. Compr Psychiatry 2oo4.

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24. Perugi G, Akiskal HS, Pfanner C, etal. The clinical impact of bipolar and uniploar affective comorbidity on obsessive – compulsive disorder. J Affect Disord 1997.

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26. Katschnig H : How useful is the concept of Quality of life in Psychiatry ? Quality of life in mental disorders. Edited by Katschnig H, Freeman H, Sartorius N. New York, John Wiley & Sons 1997.

27. Staquet MJ, Hays RD, Fayers PM (eds): Quality of life assessment in clinical trials: Methods and practice. New York, oxford university press 1998.

28. Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry 196o.

29. Broadhead WE, Blazer DG< George LK, Tse CK: depression, disability days and days lost from work in a prospective epidemiologic survey. JAMA 199o.

30. Antony MM, Roth D, Swinson RP Huta V, Devins GM:Illness intrusiveness in individuals with panic disorder, obsessive – compulsive disorder or social phobia. J Nerv Ment Dis 1998.

31. Rapaport MH, Clary C, Fayyad R, Endicott J. Quality of life impairment in depressive and anxiety.

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32. Moussavi S, Chatterji S, Verdes E etal. Depression, chronic diseases, and decrements in health: results from the World Health Survey. Lancet 2007;

370:851-858

33. Das-Munshi J, Goldberg D, Bebbington PE, etal. Publich Heath significance of mixed anxiety and depression : beyond current classification. Br. J Psychiatry 2008.

34. Strine TW, Chapman DP, Balluz LS, etal. The associations between life satisfaction and health related Quality of life, chronic illness and health behaviours among U.S. community –dwelling adults. J. Community Health 2008.

35. World Heath Organisation (1992): The ICD 10 classification of mental and behavioral disorders: diagnostic criteria for research. Geneva : World Health Organisation.

36. Emmel kamp, P.M.G., deHaan, E., Hoogduin C.A.L (1990) Marital adjustment and obsessive – compulsive disorder. British journal of Psychiatry 156,55-60

37. Chakrabarthi, S. Kulhara, P and Verma, S.K. (1993) The pattern of burden in families of neurotic patients, social Psychiatry and Psychiatric epidemiology 28, 172-177

38. Cooper, M (1993) A group of families of obsessive – compulsive persons:

The journal of contemporary human services, 74, 301-307

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39. Elizsondo, D.M, calamari, J.E, Janeck, A.S (1996) Quality of life in obsessive – compulsive disorder.

40. KIM; SW; Dysken M.W. Kushkowski, M? (1990) The yale brown obsessive – compulsive scale; a reliability and validity study Psychiatric research, 34, 99-106.

41. Didie ER, Walters MM, Pinto A, etal. A comparison of Quality of life and psychosocial functioning in obsessive – compulsive disorder and body dysmorphic disorder. Ann Clin Psychiatry 2007; 19: 181-186

42. Whitaker A, Johnson J, Shaffer D, Rapoport JL, Kalikow K, Walsh BT, Davies M, braiman S, Dolinsky A: uncommon troubles in young people;

prevalence estimates of selected Psychiatry disorders in a non referred adolescent population. Arch Gen Psychiatry 1990; 47;487-496

43. Skoog G, Skoog I: A 40 year follow up of patients with obsessive – compulsive disorder. Arch Gen Psychiatry 1999; 56: 121-127

44. Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, Heninger GR, Charney DS: The yale – brown obsessive – compulsive scale, I: development, use, and reliability. Arch Gen Psychiatry 1989; 46;

1006-1011

45. Miguel EC, Coffey BJ, Baer L, Savage CR, Rauch SL, Jenike MA:

Phenomenology of international repetitive behaviours in obsessive – compulsive disorder and Tourette’s syndrome. J Clin Psychiatry 1995;56;

246-255

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46. Gelter DA, Biederman J, Jones J, Shapiro S, Schwartz S, Park KS: obsessive – compulsive disorder in children and adolescents : a review. Harv Rev Psychiatry 1998; 5:260-273

47. Swedo SE, Leonard HL, Garvey M, Mittleman B, Allen AJ, Perimutter S, Dow S, Zan. Koff J, Dubbert BK, Lougee L: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry 1998; 155:264-271;

correction , 155:578

48. Hollander E, Kwon JH, Stein DJ, Broatch J, Rowland CT< Himelein CA.

obsessive – compulsive and spectrum disorders: Overview and Quality of life issues. J Clin Psychiatry. 1996; 57 (suppl 8) 3-6

49. Elsen JL, Mancebo MA, Pinto A, Coles ME, Pagano ME, Stout R, Rasmussen SA, Impact of obsessive – compulsive disorder on Quality of life, Compr Psychiatry

50. Rodriguez – Salgado B, Dolengevich – Segal H, Arrojo – Romero M, Castelli – Candia P, Navio- Acosta M, Perez – Rodriguez MM, Saiz Ruiz J, Baca Garcia E, Perceived Quality of life in obsessive – compulsive disorder : related factors. BMC Psychiatry

51. Calvocoressi L, Libman D, Vegso SJ, McDougle CJ, Price LH. Global functioning of in-patients with obsessive – compulsive disorder, schizophrenia, and major depression. Psychiatr Serv. 1998; 49(3): 379-81

52. Rapaport MH, Clary C, Fayyad R, Endicott J. Quality of life impairment in depressive and anxiety disorders. Am J Psychiatry 05; 162(6): l 171-8

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53. Moritz S, Rufer M, Fricke S, Karow A, Morfeld M, Jelinek L, Jacobsen D.

Quality of life in obsessive – compulsive disorder before and after treatment.

Compr Psychiatry 2005;46:453-9

54. Koran LM. Quality of life in obsessive – compulsive disorder. Psychiatr Clin North Am. 2000; 23(3):50-17

55. Vikas A, Avasthi and Sharan P Psychological impact of obsessive compulsive disorder on patients and their care givers: a comparative study with. depressive disorder. Int J Soc Psychiatry, 2009.

56.Cassin SE, Richter MA, Zhang KA, Rector NA. Quality of Life in Treatment-Seeking Patients With Obsessive–Compulsive Disorder With and Without Major Depressive Disorder. Can J Psychiatry. 2009;54(7):460–467.

57. Foa EB, Kozak MJ, Salkovskis PM, Coles ME, Amir N. The validation of a new obsessive-compulsive disorder scale: the Obsessive–Compulsive Inventory. Psychol Assess 1998; 10: 206–14.

58. Fontenelle LF, Mendlowicz MV, Marques C, Versiani M. Trans-cultural aspects of obsessive–compulsive disorder: a description of a Brazilian sample and a systematic review of international clinical studies. J Psychiatr Res 2004;38:403–11.

59. Fontenelle LF, Hasler G. The analytical epidemiology of obsessive–

compulsive disorder: Risk factors and correlates. Progress in Neuro- Psychopharmacology & Biological Psychiatry 32 (2008) 1–15.

60. Lewis A. Problems of obsessional illness. Proc R Soc Med 1986;29:325–36.

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INFORMED CONSENT

I am resident, doing MD Psychiatry in Stanley Medical College, Chennai. As part of my training, I am conducting a research among 30 persons with obsessive compulsive disorder and 30 persons with Major depression on the topic ‘A study of Clinical Features.Quality of Life in obsessive compulsive disorder’: A Case Control Study. I have prepared an interview schedule for this research, which would be administered personally to all the respondents. In addition, only for the 30 persons with obsessive – compulsive disorder, I’ll also be administering a standardized questionnaire related to their clinical symptoms.

The purpose of study :A study of Clinical Features, Quality of Life in obsessive compulsive disorder:

A Case Control Study.

Age group of the respondents: 18-60 years

Method of data collection : Personal Interviews

Tool of data collections : Interview schedule and standardized questionnaires

Time required to complete : 60 to 90 minutes

Benefits of the study : There will not be any direct benefit out

of this research. The researcher will help in increasing the awareness about the conditions under study namely, obsessive compulsive disorder and major depression. All respondents are registered in Department of Psychiatry, Stanley Medical College and will receive free

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medicines, phycho therapy and psycho education.

Use of Information collected : The information collected would be

used only for academic purposes and data confidentiality would be maintained by the researcher and the institution concerned.

Risks : Sensitive questions may be avoided if

the respondent does not feel comfortable answering them. The questions are framed only to ascertain the clinical characteristics and possible associated factors.

Contact Person : The researcher can be contacted over

the phone for any clarifications and explanations regarding this study, in the numbers +91 9443593207 or 044xxxxxxxx, Extension No. yyy, Department of Psychiatry, Stanley Medical College hospital.

If you consent to be a respondent in this research, you can clarify all your doubts from the researcher, even before the interview. Kindly sign below for proceeding further. Your participant is purely voluntary.

Signature of the Respondent : Date:

Witness : Date:

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1

INTRODUCTION

Obsessive Compulsive disorder (OCD) is a common, chronic disabling and often debilitating disorder, marked by obsessions and compulsions. Obsessions are described as recurrent intrusive, distressing thoughts, images, or impulses, which the patients recognizes as irrational.

Compulsions are repetitive behaviours or mental acts that the patient feels driven to perform to prevent or to reduce distress or feared situation.

The recognition of obsessive compulsive disorder (OCD) as a distinct mental disorder began in the 19^th century. In 1877, the German Psychiatrist West Phal used the term ‘Zwang vorstellung’ (Compelled presentation or idea) to describe OCD pathology. Nineteenth century French descriptions related this disorder to doubt or what was called

“Insanity with insight”. Esquirol (1837) and Legren du Salle (1875) related this syndrome to doubt (Folie du doute) and disease of the will (Deliredu toucher). Janet called this as psychasthenia and stressed the relationship with low mental energy. The British translated Westphal’s term as “Obsession” and the Americans as “Compulsions”.

Obsessive compulsive disorder which was once thought to be uncommon condition has been increasingly recognized now. The life time prevalence of this disorder is between 2 to 3% in general population. It is

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2 twice as prevalent as schizophrenia and bipolar disorder and the fourth most common psychiatric disorder. Above all, 50 – 60% of the OCD patients also experience two or more co-morbid psychiatric conditions during their life time. However, OCD has not received due attention of the clinicians, researchers and policy makers because it is a non psychotic illness.

OCD is being labeled a “hidden epidemic” and ranked 20^th in global burden of disease among all diseases as a cause of disability – adjusted life years lost in developed countries. Available evidence indicates that OCD patients report general impairment in their functioning, and report poor quality of life (QOL). They also suffer from disability in several areas, particularly in marital, occupational, emotional and social functioning. More severe OCD symptoms were associated with general impairment in functioning. There is evidence that even the treatment responders continue to experience poor QOL. Depression and obsessions are the symptom clusters that most strongly contribute to low QOL. Because of the demoralization and hopelessness caused by obsessive compulsive symptoms, these patients view their life as worthless, but studies on clinical features and quality of life in obsessive compulsive disorder, compared to depression are very few which made us to take up this study.

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3 In view of significance of quality of life as an indication of needs for care for the population that is being studied, I chose to study this aspect among the Obsessive Compulsive Disorder, a neglected field in Psychiatry. It was proposed to study the clinical features and assess the quality of life in them in comparison with another disabling condition, namely, major depression.

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4

REVIEW OF LITERATURE

The quality of life (QOL) is increasingly recognized as a pivotal outcome parameter in research on obsessive – compulsite disorder (OCD).

Studies using generic (ie – illness unspecific) instruments have confirmed poor QOL in OCD patients across a wide range of domains, especially with respect to social, work role functioning and mental health aspects.

A comprehensive definition is provided by the World Health Organization (WHO) which described QOL as the individuals perception of their position in life, in the context of the culture and value systems in which they live, and in relation to their goals, expectations standards and concerns. A common denominator of health related QOL scales in the individuals perspective on multiple dimensions including functional (eg) work, physical, psychological and social aspects.

As early as 1975, persons with OCD are reported to have mild to moderate level of disturbance in several functions (Marks et al 1975).

These findings were replicated by Foa and Goldstein in 1978.

According to a Canadian survey impairment and distress were experienced from obsessions by 26% and from compulsions by 22%. The

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5 ECA study reported findings on employment and marital status showed significant functional impairment and high mental health care utilization.

Leon and others (1995) noted that 22% of men and 13% of women with OCD were receiving disability payments. Overall 20 – 30% of men and women with OCD received some type of financial assurance.

Koran and others (1996) found that 22% of treatment seeking OCD samples was unemployed. Handerson and pollard (1988) did not find significant difference in income levels between adults diagnosed with OCD and without this disorder.

According to ECA findings 21% of OCD – diagnosed respondents were single. Karno and others (1988) stated OCD more often occurs among divorced or separated respondents, although marital disruption was not specific to OCD. Early onset of illness in males may lead to remaining single thought the rest of their life.

Rapaport et al compared quality of life impairment in depressives and anxiety disorders. The proportion of patients with clinically severe impairment (two or more standard deviations below the community norm) in quality of life, varied with different diagnosis – major depressive disorder (63%) chronic / double depression (85%) dysthymic disorder 56% OCD (26%) PTSD (59%).

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6 Bobes et al compared the quality of life in Spanish population with depressed outpatients, patients on haemodialysis, and kidney transplant recipients – OCD patients reported the same quality of life as schizophrenics in the areas of mental health, but better in the areas of physical health compared with heroin dependents and depressed patients, their quality of life was worse.

In a study by Nideauer, and others on the quality of life in individuals with OCD, the social and familial relationships and the occupational performance (capacity to work and study) were the areas most severely affected by the disorder, and although there was an improvement with the treatment, these areas remain at a poor level of performance.

Stengler Wenzke (2006) and others compared the subjective quality of life (QOL) in patients with OCD and general population and to patients with schizophrenia and concluded that OCD has a substantial adverse effect on patients subjective QOL which may be even greater than the adverse effects of schizophrenia.

Stengler – Wenzke (2007) and others found compulsions reduced patient QOL where as obsessions did not have any impact on QOL

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7 ratings. Depressive symptoms were strong predictors of QOL in OCD patients.

Fineberg NA, Fouril H, Gale TM, Sivakumaran T (2005) UK, compared OCD patients with comorbid depression to a group patients with major depression (MDD) and found that the OCD groups was significantly more symptomatic and items 3 (inner tension) and 9 (pessimistic thoughts) and less symptomatic on items 4 (sleep) and 5 (appetite).

Calvocoressi (1988) compared in patient group of OCD with.

Schizophernia and depressive disorder group. He concluded that these groups had worse employment histories, lost more time from work, and poorly performed activities of daily living.

Social adjustment and social functioning was found to be moderately impaired in out patient OCD population, mild to moderate problems in outpatient samples in the areas of family functioning was reported.

Sexual dissatisfaction upto 70% of outpatient sample (Steketee 1977) staebler and other (1993) compared sexual dissatisfaction in outpatient group with panic disorder and depression, reported upto 60%

had dissatisfaction, but qualitatively not different from other groups.

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8 In a study conducted by Moritz (2008) and colleagues found 2-4 standard deviations lower than those of a healthy subsample on the role physical, general health, vitality, social functioning, role emotional.

Gururaj GP, Badamath. S., and others (2008) from OCD clinic, Dept. from Psychiatry, NIMHANS, Bangalore, India, compared OCD and schizophrenic patients and concluded that severe OCD is associated with significant disability, poor quality of life, often comparable to schizophrenia.

Vikas A, Avasthi and others from Chandigarch, India (2009) compared the QOL with depressive disorder patients and found that patients with OCD had a better quality of life (QOL) and were less disabled compared with depressed patients.

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AIMS AND OBJECTIVES

• To describe the clinical features of obsessive compulsive disorder.

• To assess the quality of life among obsessive compulsive disorder.

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MATERIALS AND METHODS

SETTING OF STUDY

The study was carried out at the psychiatry OPD at Government Stanley Medical College and Hospital, Chennai.

STUDY PERIOD

The study was carried out over a six month period from January 2009 to June 2009.

STUDY SAMPLE

30 consecutive patients who satisfied the criteria for obsessive compulsive disorder and 30 patients who satisfied the criteria for depression according to ICD 10 diagnostic criteria were recruited for the study.

DESIGN OF STUDY

Case Control Study.

SELECTION OF SAMPLE

30 consecutive patients fulfilling the inclusion criteria were taken as the study sample.

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11 30 consecutive patients fulfilling the inclusion criteria were taken as the control population.

INCLUSION CRITERIA

1. Diagnosed as obsessive compulsive disorder according to ICD 10 criteria.

2. Duration of illness greater than six months.

3. No evidence of organic disease.

4. Willing to provide informed consent for the interview.

EXCLUSION CRITERIA

1. Uncooperative patients

2. Refusal to participate in the study.

3. Duration of illness less than six months.

4. Patients with evidence of organic disease.

5. OCD with psychotic features.

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12 CONTROLS

30 consecutive patients who satisfied the criteria for depression according to ICD 10 diagnostic criteria attending the OPD, Stanley Medical College Hospital, Chennai.

INCLUSION CRITERIA

1. Diagnosed as Depression according to ICD 10 criteria.

2. Willing to provide informed consent for the interview.

3. No evidence of organic disease.

EXCLUSION CRITERIA

1. Uncooperative patients

2. Refusal to participate in study.

3. Patients with evidence of organic disease.

4. Depression with psychotic features.

TOOLS

1. Semi structured proforma for socio demographic Data,

* Age

* Sex

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13

* Educational Status

* Marital Status

* Employment Status

* Socio economic status

* Family history

2. Self checklist for Obsessive – Compulsive disorders (OCD) 3. Yale Brown obsessive compulsive scale (Y Bocs)

4. Hamilton Depression rating scale (Ham-D).

5. World Health Organization Quality of life (WHO QOL) BREF.

YALE-BROWN OBSESSIVE COMPULSIVE SCALE-YBOCS.

The Y-BOCS developed by W.Goodman et al., is used to measure the severity of symptoms in obsessive compulsive disorder. It has questions which are divided in to two domains-have five questions each.

One is for obsessions and another is for compulsions. The response to each question is rated on likert type of scoring from 0-4, where ‘o’

denotes no active symptoms and ‘4’ indicates severe symptoms. The total score for each item is added together to get the totaldomain score for obsession and compulsion. These two scores put together will give the

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14 total score on both obsession and compulsions. The total score out of 40 is then grouped in to subclinical to extreme score.

QUESTIONS

1. Time spent 2. Interference 3. Distress 4. Resistance

5. Control over symptom RANGE OF SEVERITY

0-7 subclinical 8-15 mild 16-23 moderate 24-31 severe 32-40 extreme

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15 HAMILTON DEPRESSION RATING SCALE, (HDRS)

The HDRS (also known as HAM-D) is the most widely used clinician administered depression assessment scale. The original version contain 17 items (HDRS17) pertaining to symptoms of depression experienced over the past 2 week.

SCORING

Method for scoring varies by version for the HDRS 17 a score of 0- 7 is generally accepted to be within the normal range (or in clinical remission) while a score of 20 or higher indicating atleast moderate severity is usually required for entry in to a clinical trial Numerous versions with varying lengths include the HDRS 17. HDRS 21, HDRS 29, HDRS 8, HDRS 6, HDRS 24, HDRS 7, in this study HDRS17 is used.

PROCEDURE

The thesis and its methodology were discussed and approved by the Ethics committee of the research panel of Stanley medical college, Chennai Subjects in this study consisted of thirty patients of obsessive compulsive disorder and thirty patients of depression from the out patient department of Stanley medical college hospital Chennai. All the patients were diagnosed using the ICD -10 diagnostic criteria.

Informed consent was obtained from each patient.

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16 The scales were applied at the time of the study measuring the current status.

The data thus collected was tabulated and discussed with reference to the aims and objectives the study

ANALYSIS

The cases and controls were analysed for the study findings.

Frequency distribution was done using EPI 6 Info (WHO). For comparison, we used chi square tests for testing the association and the difference in means was calculated using student ‘t’ test. These tests were performed using SPSS version 16. In addition, we generated some charts using the Microsoft word. Important findings of relevance, both positive and negative are presented and discussed.

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RESULTS AND DISCUSSION

As this is a case control study, I compared the cases and controls for various characteristics.

SOCIO DEMOGRAPHIC INFORMATION

The cases and controls were compared for the following: age, gender, marital status, living status, religion, educational level and employment status.

TABLE - 1

COMPARISON OF AGE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION (CONTROLS)

Cases/Controls N Mean Std.

Deviation

df ‘t’

value

‘p’

value Cases (OCD) 30 29.3333 7.64890

58 -2.448 .017*

Controls (Depression)

30 36.3000 13.58028

Compared with depressives, OCD patients are younger and this difference is statistically significant (p = 0.017).

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TABLE - 2

COMPARISON OF GENDER BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

Cases/Controls N Males females df

‘chi’

value

‘p’

value

Cases (OCD) 30 19 11

1 5.406 0.019*

30

10 20

Compared with depressives, there are more male OCD patients this difference is statistically significant (p = 0.019).

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19

TABLE – 3

COMPARISON OF MARITAL STATUS BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

Cases/Controls N Married Unmarried df

‘chi’

value

‘p’

value

1 3.59 0.058 Controls

(Depression)

30

23 7

There is no statistical difference for marital status between the cases and controls.

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20

TABLE – 4

COMPARISON OF LIVING STATUS BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

Cases/Controls N

With parents

With Spouse

df

‘chi’

value

‘p’

value

1 7.5 0.006*

30

5 25

There is statistically significant difference for living status between the cases and controls; more people with OCD are living with parents compared with depressive patients.

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21

TABLE – 5

COMPARISON OF LIVING ARRANGEMENT

(ACCOMMODATION) BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION (CONTROLS)

Cases/Controls N Own

Rental

&

Others

df ‘chi’

value

‘p’

value

1 3.59 0.058 Controls

(Depression)

30

7 23

There is no statistically significant difference for living arrangement between the cases and controls.

(37)

22

TABLE – 6

COMPARISON OF RELIGION BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

Cases/Controls N Hindus Others df

‘chi’

value

‘p’

value

Cases (OCD) 30 24 6

1 0.48 0.488 Controls

(Depression)

30 26 4

There is no statistically significant difference for religion between the cases and controls.

(38)

23

TABLE – 7

COMPARISON OF EDUCATIONAL LEVEL BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

DEPRESSION (CONTROLS)

Illiterate and Primary

Secondary and above

df

‘chi’

value

‘p’

value

Cases (OCD) 30 5 25

1 8.86 0.003**

Controls

(Depression) 30 16 14

There is statistically significant difference for educational level between the cases and controls; more OCD patients have secondary and high levels of education compared with depressive patients.

(39)

24 TABLE - 8

COMPARISON OF EMPLOYMENT STATUS BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/

Controls N Unemployed Employed

Others (Student/

housewife)

df ‘chi’

value

‘p’

value

Cases (OCD) 30 7 16 7

2 3.275 0.77 Controls

(Depression)

30 5 15 10

TABLE - 9

COMPARISON OF RURAL/URBAN STATUS BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/Controls N Urban Semi

Urban Rural df ‘chi’

value

‘p’

value

Cases (OCD) 30 19 4 7

2 0.32 0.852 Controls

(Depression) 30 21 3 6

There is no statistically significant difference for urban/rural status between the cases and controls.

In summary, the OCD patients are younger, predominantly males, more educated and living with parents compared with depressives. On the other hand, these two groups are comparable for their socio economic background and employment status.

(40)

25 FAMILY HISTORY

TABLE – 10

COMPARISON OF FAMILY HISTORY OF PSYCHIATRIC ILLNESS BETWEEN OBSESSIVE COMPULSIVE DISORDER

(CASES) AND DEPRESSION (CONTROLS)

Family History of Psy Disoder +

No Family History of Psy Disoder

df ‘chi’

value

‘p’

value

1 2.052 0.126 Controls

(Depression) ^{30 6 24}

It is important to observe that 36.7 % of OCD patients have a family history of psychiatric disorder compared with 20 % of depressive patients but this difference was not statistically significant.

TABLE - 11

COMPARISON OF FAMILY HISTORY OF SUBSTANCE USE, INCLUDING ALCOHOL BETWEEN OBSESSIVE COMPULSIVE

DISORDER (CASES) AND DEPRESSION (CONTROLS)

Alcohol or substance

use in family member

No Alcohol or

substance use in family member

df ‘chi’

value

‘p’

value

Cases (OCD) 30 6 24

1 0.48 0.365 Controls

It is observed that no statistically significant difference exist between the two groups for family history of substance use.

(41)

26 TABLE - 12

COMPARISON OF FAMILY HISTORY OF SUICIDE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/

Controls N

Suicide/attempte d suicide in family member

No

Suicide/attempted suicide in family

member

df ‘chi’

value

‘p’

value

Cases (OCD) 30 6 24

1 0.373 0.381 Controls

(Depression)

30 8 22

It is observed that no statistically significant difference exist between the two groups for family history of suicide / attempted suicide.

Overall, there exists no difference between the cases and controls in family history of psychiatric disorder, substance use and suicide/attempted suicide.

SUBSTANCE USE HISTORY

TABLE - 13

COMPARISON OF HISTORY OF TOBACCO USE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

History of tobacco

use

No tobacco

use

df ‘chi’

value

‘p’

value

Cases (OCD) 30 2 28

1 0.218 0.5 Controls

It is observed that no statistically significant difference exist between the two groups for history of tobacco use.

(42)

27 TABLE – 14

COMPARISON OF HISTORY OF ALCOHOL USE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

History of alcohol

use

No alcohol

use

df ‘chi’

value

‘p’

value

Cases (OCD) 30 6 24

1 2.308 0.127 Controls

It is observed that no statistically significant difference exist between the two groups for history of alcohol use.

TABLE – 15

COMPARISON OF HISTORY OF DRUG USE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

History of drug

use

No drug

use

df ‘chi’

value

‘p’

value

Cases (OCD) 30 2 28

1 2.069 0.246 Controls

(Depression)

30 0 30

It is observed that no statistically significant difference exist between the two groups for history of drug use.

(43)

28 MEDICAL HISTORY

TABLE - 16

COMPARISON OF PAST HISTORY OF MEDICAL ILLNESS BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES)

AND DEPRESSION (CONTROLS)

Past History

of medical

illness

No Past History

of medical

illness

df ‘chi’

value

‘p’

value

Cases (OCD) 30 2 27

1 5.189 0.024*

30 9 21

It is observed that there is a statistically significant difference between the two groups for past history of medical illness. Compared with OCD patients, depressives have more past history of medical illnesses.

PSYCHIATRIC HISTORY

TABLE - 16

COMPARISON OF PAST HISTORY OF MEDICAL ILLNESS BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES)

Past History of psychiatric

treatment

No Past History of psychiatric

treatment

df ‘chi’

value

‘p’

value

Cases (OCD) 30 8 22

1 0.373 0.381 Controls

(Depression)

30 6 24

It is observed that there is no statistically significant difference between the two groups for past history of psychiatric treatment.

(44)

29 CLINICAL FEATURES OF OBSESSIVE COMPULSIVE DISORDER

The clinical features of the thirty patients with Obsessive Compulsive Disorder was studied in greater detail. Clinical description of the patients were recorded in detail utilizing the psychiatric interview schedule that is used in our clinic settings. Content analysis of the mental status examination was done and examples of specific obsessions and compulsions noticed in this group is presented.

In our study 30 patients fulfilled the criteria of obsessive compulsive disorder. Out of 30 patients 13 patients had “fear of contamination” and an equal number presented with “washing”

compulsion. Most of the studies in India and the world found that the fear of contamination is the commonest obsession and washing is the commonest compulsion amongst OCD patients.

In our study four patients had pathological doubt with checking compulsion. Among the four patients, one patient had mixed obsessive (sexual obsessions) features.

(45)

30 Three patients had obsessive thought of fear of harming others (aggression).

Three patients had obsession for symmetry.

The compulsions seen in the study participants included:

cleaning/washing, checking, repeating acts, order and symmetry, mental compulsions and counting. These clinical features are similar to what is being observed in most clinical studies of Obsessive Compulsive Disorder.

(46)

31 The thirty patients with OCD were administered Y-BOCS scale and the results are as follows.

TABLE - 17

FREQUENCY DISTRIBUTION OF SEVERITY OF OBSESSION AND COMPULSION SYMPTOMS ELICITED BY Y-

BOCS IN PATIENTS WITH OBSESSIVE COMPULSIVE DISORDER (N =30)

Symptoms None Mild Moderate Severe Extreme

1 0 1 (3.3%) 4 (13.3%) 14

(46.7%)

11 (36.7%)

2 0 0 3 (10%) 14

(46.7%)

13 (43.3%)

3 0 0 3 (10%) 14

(46.7%)

13 (43.3%)

4 0 0 3 (10%) 8 (26.7%) 19

(63.3%)

5 0 0 2 (6.7%) 6 (20%) 22

(73.3%) 6 5 (16.7%) 4 (13.3%) 7 (23.3%) 13

(43.3%)

1 (3.3%)

7 5 (16.7%) 3 (10%) 4 (13.3%) 13 (43.3%)

5 (16.7%)

8 6 (20%) 2 (6.7%) 4 (13.3%) 14 (46.7%)

4 (13.3%)

9 5 (16.7%) 1 (3.3%) 4 (13.3%) 10 (33.3%)

10 (33.3%) 10 5 (16.7%) 1 (3.3%) 4 (13.3%) 4 (13.3%) 16

(53.3%)

(47)

32 OBSESSIONS

FIGURE – 1

SEVERITY OF OBSESSION SYMPTOMS

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Y-BOCS 1 Y BOCS 2 Y BOCS 3 Y BOCS 4 Y BOCS 5

Severe Extreme

About a half of the patients (46.7%) spent more than three hours but less than 8 hours every day on obsessions; more than a third of them (36.7%) spent more than 8 hours every day on their obsessions. About a half of OCD patients (46.7%) had impaired levels of functioning due to their obsessions and 43.3% of the patients had incapacitating levels of interference due to their obsessions. Distress due to obsessions was severe in 46.7% of cases and near constant and disabling among 43.3% of OCD patients. About three fourths (73.3%) of the OCD patients had no control over their obsessions. About two thirds of OCD patients (63.3%) completely yielded to their obsessions.

(48)

33 COMPULSIONS

FIGURE – 2

SEVERITY OF COMPULSION SYMPTOMS

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Y-BOCS 1 Y BOCS 7 Y BOCS 8 Y BOCS 9 Y BOCS 10

Severe Extreme

Of the 30 OCD patients, 43.3% of them spent between 3-8 hours on their compulsions every day. Same proportion of patients (43.3%) experienced inpaired levels of functioning due to their compulsions.

About a half (46.7%) of the OCD patients had severe degree of distress as an adverse consequence to their compulsions. Two- thirds (66.6%) of each of OCD clients studied often yielded or completely yielded to their compulsions. More than a half (53.3%) of the OCD patients had no control over their compulsions.

(49)

34

FIGURE 3

MEAN SCORES FROM Y-BOCS FOR TOTAL, OBSESSION AND COMPULSION

0 5 10 15 20 25 30

Mean

Obsession Score Compulsion Score Total Score

Overall, it is apparent that majority of the patients have obsessions and compulsions that afflict them significantly and cause marked distress and dysfunction.

(50)

35 DEPRESSIVE SYMPTOMS AMONG OBSESSIVE COMPULSIVE DISORDER PATIENTS

The cases and controls were compared for depressive score obtained through Hamilton Depression Rating scale (HAM D)

TABLE – 1

COMPARISON OF HAM D TOTAL SCORE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/Controls N Mean Std.

Deviation df ‘t’

value

‘p’

value Cases (OCD) 30 16.6 8.5646

57 .*

Controls

(Depression) 29 26.3 4.936

Compared with OCD patients, depressives have a higher mean score in HAM D. Yet it important to note that the mean score of HAM D among OCD patients is 17 (16.6) and the cut-off score in HAM D for significant depression is

(51)

36 PROPORTION OF OCD PATIENTS WITH NO DEPRESSIVE SYMPTOMS

HAM D Symptom % of absent or no symptom

1. Depressed Mood 2 (6.6%)

2. Feelings of guilt 5 (16.7%)

3. Suicide 14 (46.7%)

4. Insomnia Early night 11 (36.7%)

5. Insomnia Middle night 15 (50%)

6. Insomnia Early morning 16 (53.3%)

7. Work and activity 6 (20%)

8. Retardation 22 (73.3%)

9. Agitation 4 (13.3%)

10. Anxiety Psychic 4 (13.3%)

11. Anxiety Somatic 1 (3.3%)

12. Somatic gastrointestinal 25 (83.3%)

13. General somatic 12 (40%)

14. Genital symptoms 22 (73.3%)

15. Hypochondriasis 18 (60%)

16. Loss of weight 25 (83.3%)

17. Insight 30 (100%)

(52)

37 QUALITY OF LIFE – RATING

TABLE – 18

COMPARISON OF QUALITY OF LIFE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

Cases/Controls N Very

poor Poor Neutral Good df ‘chi’

value

‘p’

value

Cases (OCD) 30 9 7 11 2

3 9.399 0.024*

Controls

(Depression) 30 16 11 2 1

The quality of life is very poor among the depressives compared with obsessive compulsive disorder and this difference was statistically significant.

TABLE - 19

COMPARISON OF QUALITY OF LIFE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

Cases/Controls N Very

dissatisfied Dissatisfied Neutral Satisfied df ‘chi’

value

‘p’

value

Cases (OCD) 30 9 11 7 3

3 3.475 0.324 Controls

(Depression)

30

8 13 9 0

The quality of life rating for satisfaction is similar among the depressives and obsessive compulsive disorder patients with no statistically significant difference.

(53)

38 EXPERIENCE, LAST FOUR WEEKS

TABLE – 20

COMPARISON OF PHYSICAL PAIN BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

Cases/Controls N Not at all

Little Moderate

Very much

Extreme df

‘chi’

value

‘p’

value Cases (OCD) 30 2 2 7 10 9

4 24.111 0.000 Controls

(Depression)

30 0 1 2 0 27

Compared with OCD patients, depressives experience more physical pain and the difference is statistically significant.

TABLE - 21

COMPARISON OF NEED FOR MEDICAL TREATMENT BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES)

Cases/Controls N Extreme Very

much df ‘chi’

value

‘p’

value

Cases (OCD) 30 9 21

1 0.341 0.386 Controls

There is no difference in need for medical treatment between the OCD patients and depressives.

(54)

39 TABLE - 22

COMPARISON OF ENJOYING LIFE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

Cases/Controls N Not at all

Little Moderate Extreme df ‘chi’

value

‘p’

value Cases (OCD) 30 6 19 5 0

3 5.622 0.132 Controls

(Depression)

30

13 14 2 1

Comparison between the two groups reveal no statistically significant difference between the item ‘enjoying the life’.

TABLE – 23

COMPARISON OF MEANINGFULNESS OF LIFE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/Controls N Not

at all Little Moderate Very

value

‘p’

value Cases (OCD) 30 3 18 7 2

3 7.358 0.061 Controls

(Depression)

30 12 13 4 1

More depressive patients than OCD patients state that life is not meaningful at all and this difference is statistically significant.

(55)

40 TABLE - 24

COMPARISON OF CONCENTRATION BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

at all

Little Moderate df ‘chi’

value

‘p’

value

Cases (OCD) 30 8 19 3

2 0.912 0.634 Controls

There is no difference in concentration between the OCD patients and depressives.

TABLE - 25

COMPARISON OF FEELING OF SAFETY BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

at all

Little Moderate

Very much

df

‘chi’

value

‘p’

value

Cases (OCD) 30 4 11 14 1

3

1.813

0.612 Controls

No statistically significant difference was observed for feeling of safety between the two groups.

(56)

41 TABLE - 26

COMPARISON OF PHYSICAL ENVIRONMENT BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

at all

Little Moderate Very

value

‘p’

value

Cases (OCD) 30 2 0 7 21

3 9.621 0.022*

Controls

More OCD patients experience more healthy physical environment compard with depressives and this difference is statistically significant.

EXPERIENCE OR ABLE TO DO CERTAIN THINGS, LAST FOUR WEEKS

TABLE – 27

COMPARISON OF ENERGY BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

at all

Little Moderate Mostly df ‘chi’

value

‘p’

value Cases (OCD) 30 2 13 14 1

3 8.388 0.039*

Controls

More OCD patients have moderate levels of energy compared with depressives and this difference is statistically significant.

(57)

42 TABLE - 28

COMPARISON OF BODY APPEARANCE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/

Controls N

Not at all

Little Moderate Mostly Completely df ‘chi’

value

‘p’

value Cases (OCD) 30 2 4 4 18 2

4 7.429 0.115 Controls

(Depression) 30

0 1 11 17 1

There was no statistically significant difference between the two groups for body appearance.

TABLE - 29

COMPARISON OF MONEY TO MEET NEEDS BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/

Controls N

Not at all

Little Moderate Mostly df ‘chi’

value

‘p’

value Cases

(OCD) 30 1 6 18 5

3 11.045 0.011*

Controls

More OCD patients have money to meet needs compared with depressives and this difference is statistically significant.

(58)

43 TABLE - 29

COMPARISON OF INFORMATION BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

Cases/

Controls

N Moderate Mostly Completely df

‘chi’

value

‘p’

value Cases (OCD) 30 2 25 3

2

5.861 0.053 Controls

(Depression)

30 7 23 0

No statistically significant difference was observed between the two groups for information.

TABLE - 30

COMPARISON OF LEISURE ACTIVITY BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

Cases/Controls N Little Moderate Mostly df ‘chi’

value

‘p’

2 0.112 0.945 Controls

Leisure activity was similar in the two groups.

(59)

44 TABLE – 31

COMPARISON OF ABILITY TO GET AROUND BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/

Controls N Very

poor Poor Neutral Good Very

good df ‘chi’

value

‘p’

value Cases (OCD) 30 0 2 0 13 15

4 21.069 0.000 Controls ***

(Depression) 30 1 5 6 17 1

More OCD patients have ability to get around compared with depressives and this difference is statistically significant.

TABLE - 32

COMPARISON OF SLEEP BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

Cases/

dissatisfied Dissatisfied Neutral Satisfied df ‘chi’

value

‘p’

value Cases (OCD) 30 5 10 8 7

3 14.73 0.002

**

Controls

More OCD patients have better sleep compared with depressives and this difference is statistically significant.

(60)

45 TABLE - 33

COMPARISON OF DAILY PERFORMANCE ABILITY BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES)

Very dissatisfied

Dissatisfied Neutral Satisfied df

‘chi’

value

‘p’

value

Cases (OCD) 30 6 13 3 8

3 1.426 0.7 Controls

(Depression) 30

6 17 2 5

The daily performance ability was similar between the two groups and there was no statistically significant difference.

TABLE - 34

COMPARISON OF CAPACITY FOR WORK BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/

dissatisfied Dissatisfied Neutral Satisfied df ‘chi’

value

‘p’

value Cases

(OCD) 30 4 13 7 6

3 3.501 0.321 Controls

There was no statistically significant difference between the two groups for capacity for work.

(61)

46

TABLE - 35

COMPARISON OF SATISFACTION WITH WORK BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/

Controls N

Dissatisfied Neutral Satisfied df

‘chi’

value

‘p’

value Cases (OCD) 30 7 17 3 3

3 1.25 0.741 Controls

The satisfaction with work was similar between the two groups and there was no statistically significant difference.

TABLE - 36

COMPARISON OF PERSONAL RELATIONSHIP BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases /Controls

N

Dissatisfied Neutral Satisfied Very Satisfied

df

‘chi’

value

‘p’

value Cases

(OCD)

30

1 4 10 13 2

4 9.214 0.056 Controls

(Depression) 30

6 9 7 8 0

There was no statistically significant difference between the two groups for personal relationship

(62)

47 TABLE - 37

COMPARISON OF SUPPORT FROM FRIENDS BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/

dissatisfied Dissatisfied Neutral Satisfied df ‘chi’

value

‘p’

value Cases (OCD) 30 2 18 9 1

3 1.837 0.607 Controls

No statistically significant difference was observed for support from friends between the two groups

TABLE – 38

COMPARISON OF LIVING PLACE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND DEPRESSION

(CONTROLS)

Cases/ Controls N Very

dissatisfied Dissatisfied Neutral Satisfied Very

Satisfied df ‘chi’

value

‘p’

value

Cases (OCD) 30 1 2 4 22 1

4 7.294 0.121 Controls

(Depression) 30 0 1 0 29 0

There was no statistically significant difference between the two groups for living place.

(63)

48 TABLE – 39

COMPARISON OF ACCESS TO HEALTH SERVICE BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/Controls N Dissatisfied Neutral Satisfied Very

value

‘p’

value Cases (OCD) 30 1 1 26 2

3 4.286 0.232 Controls

No statistically significant difference was observed for health service between the two groups.

TABLE - 40

COMPARISON OF TRANSPORTATION ACCESS BETWEEN OBSESSIVE COMPULSIVE DISORDER (CASES) AND

Cases/Controls N Dissatisfied Neutral Very

value

‘p’

2 3.158 0.206 Controls

The transportation was similar between the two groups and there was no statistically significant difference.